三腔二囊管辅助急诊内镜下治疗食管胃底静脉曲张破裂出血的临床研究

目的探讨三腔二囊管在辅助急诊内镜下组织胶注射术联合硬化剂注射、静脉曲张套扎治疗食管胃底静脉曲张破裂出血的作用。方法按就诊先后顺序选择60例患者,并采用单盲随机法分为研究组及对照组各30例,研究组运用三腔二囊管辅助急诊内镜下组织胶注射术联合硬化剂注射、静脉曲张套扎治疗食管胃底静脉曲张破裂出血,对照组运用常规急诊内镜下组织胶注射术联合硬化剂注射、静脉曲张套扎治疗食管胃底静脉曲张破裂出血,对两组疗效进行比较。结果研究组30例患者治疗均获成功,止血效率为100.00%(30/30),明显高于对照组的76.67%(23/30),差异有统计学意义(P0.05)。研究组食管胃底静脉曲张治疗后消失率为63.33%(19/30),明显高于对照组的14.28%(4/28),差异有统计学意义(P0.05)。胸痛和发热、总住院天数和总医疗费用研究组明显低于对照组(P0.05)。结论采用三腔二囊管辅助急诊内镜下组织胶注射术联合硬化剂注射、静脉曲张套扎治疗食管胃底静脉曲张破裂出血可提高治疗效率,减少患者并发症的发生及经济负担。     

α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张破裂出血的临床观察

目的评价经内镜注射组织黏合剂α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张的临床疗效及不良反应。方法 18例临床确诊的肝硬化合并急性胃静脉曲张破裂出血的患者中,活动出血5例,近期出血13例,胃静脉曲张Sarin分类胃食管静脉曲张Ⅰ型（GOV1）7例,胃食管静脉曲张Ⅱ型（GOV2）8例,孤立性胃静脉曲张Ⅰ型（IGV1）7例,在静脉滴注奥曲肽的同时,经内镜首先选择靶静脉及穿刺点,根据曲张静脉的直径确定组织黏合剂的剂量,依次对胃曲张静脉采用三明治法进行组织黏合剂栓塞治疗,11例合并食管静脉曲张的患者在栓塞治疗后联合食管曲张静脉套扎治疗,术后进行内镜随访,观察止血成功率、早期再出血率、病死率、静脉曲张消退情况以及不良反应。结果急诊止血成功率100%,早期再出血率0%、静脉曲张消退显效13例（72.2%）,有效3例（16.7%）,无效2例（11.1%）;3例出现术后低热,1例出现大肠杆菌败血症;11例注射部位出现糜烂,4例注射部位形成溃疡;1例术中出血。结论经内镜注射组织黏合剂α-氰丙烯酸烷基酯栓塞治疗胃静脉曲张破裂出血是一种简便、安全、有效的方法。     

内镜下钛夹联合组织胶治疗GOV2 型胃底静脉曲张30 例*

目的总结该院30例应用内镜下钛夹联合组织胶预防和治疗GOV2型胃底静脉曲张的临床经验,初探钛夹辅助治疗的临床应用价值。方法收集该院2015年5月-2016年12月GOV2型胃底静脉曲张患者病例资料(包括急性出血和一级预防)30例行病例分析,分析钛夹辅助治疗对术中组织胶注射、术中出血、术后静脉消除、再出血结局,以及排胶出血、异位栓塞发生的影响。结果术中平均组织胶用量(1.46±0.70)ml,平均钛夹用量5或6个,术中拔针出血2例(6.7%)。术后共14例患者(46.7%)行内镜下复查,静脉消除者3例(10.0%),残留者11例(36.7%);随访期内再出血4例(13.3%),死亡2例(6.7%),1例为术后呕血,失血性休克死亡;另1例术后发生自发性腹膜炎,感染性休克死亡。总体疗效看,治愈2例(6.7%),好转22例(73.3%),未愈6例(20.0%,包括再出血4例,死亡2例);术后17例患者行门静脉CT血管成像检查,无1例发生异位栓塞。术后排胶出血1例(3.3%),余患者无严重术后并发症发生。结论内镜下钛夹联合组织胶可应用于预防、治疗GOV2型胃底静脉曲张,或可提高治疗效果,降低术中(或)术后出血、异位栓塞风险,具有良好的临床应用价值,值得进一步临床研究。     

不同食管静脉曲张内镜治疗方法对门静脉高压性胃病的影响

目的: 分析研究不同的食管静脉曲张内镜治疗方法对门静脉高压性胃病（portal hypertensive gastropathy,PHG）的影响。方法: 连续收集2015年1月至2016年3月上海交通大学医学院附属瑞金医院消化科收治的食管静脉曲张内镜治疗患者共35例,给予内镜下硬化剂注射治疗（endoscopic injection sclerotherapy,EIS）或内镜下静脉曲张套扎术（endoscopic varix ligation,EVL）,对合并的胃静脉曲张同时给予黏合剂注射栓塞治疗。术后定期随访,随访过程中酌情追加内镜治疗,并评估患者PHG的动态变化。结果: 首次接受EIS及EVL的患者分别为17与18例;随访中,上述2组中各有16、13例患者分组不变,其余6例因操作原因、EIS后消退不理想或残余曲张静脉不适合再次行EVL而改用另一种内镜治疗（混合治疗）,平均内镜随访时间为（8.6±4.0）个月。内镜治疗前无PHG的患者17例,轻度PHG者为18例,无重度PHG患者;治疗后,无PHG、轻度PHG、重度PHG者分别为16例、16例、3例（P>0.05）。EVL与混合治疗在控制出血和维持PHG稳定方面似优于EIS,治疗前、后患者的平均总体肝功能Child评分分别为（6.77±1.73）分和（6.00±0.91）分,内镜治疗后患者的肝功能明显改善（P<0.01）。结论: 食管静脉曲张内镜治疗不会对PHG产生明显负面影响。     

胃镜下硬化术联合组织胶注射术治疗食管胃底静脉曲张破裂出血的临床研究

目的：探讨胃镜下硬化术联合组织胶注射术治疗食管胃底静脉曲张破裂出血的临床效果。方法：选取2019年10月至2011年10月河南省南阳市中心医院接受治疗的139例食管胃底静脉曲张破裂出血患者作为研究对象,按照治疗方法不同将患者分成对照组69例和观察组70例。对照组患者在胃镜下行硬化术,观察组患者在胃镜下行硬化剂联合组织胶注射术。对比两组患者胃镜下术后并发症发生情况、食管胃底静脉曲张治疗效果情况、止血成功率。结果：观察组患者术后并发症低于对照组患者（P<0.05）;观察组患者治疗总有效率高于对照组患者（P<0.05）;观察组患者的止血成功率明显高于对照组患者（P<0.05）。结论：胃镜下硬化术联合组织胶注射术治疗食管胃底静脉曲张破裂出血可提高止血成功率及治疗疗效。     

内镜序贯治疗肝硬化食管胃底静脉曲张的疗效分析

目的评价内镜序贯治疗肝硬化食管胃底静脉曲张的临床效果。方法回顾性分析经内镜序贯治疗的193例肝硬化食管胃底静脉曲张患者,采取规范的一级、二级预防,依据静脉曲张分型、分级采用不同内镜治疗方法,按时间节点定期随访序贯治疗,总结评估内镜治疗时机、方法合理性及短期、长期疗效。结果 193例患者胃镜下见食管静脉曲张186例,合并胃底静脉曲张103例,近贲门部胃底静脉曲张4例,IGV1型3例。行食管静脉曲张套扎(EVL)178例,贲门部套扎5例,胃底密集套扎(DEVL)9例,胃底组织胶注射96例,食管套扎点平均7.12环;胃底套扎7～14环,组织胶注射1.0～5.0 ml;平均治疗食管2.68次、胃底1.07次。第1次内镜治疗后静脉曲张消除51例(26.42%)、缓解140例(72.54%)、无效2例(1.04%),治疗有效率为98.96%;1个月后再行治疗,静脉曲张消除113例(58.55%),缓解28例(14.51%),无效1例(0.52%);3个月后再次内镜治疗,静脉曲张完全消除23例(11.92%),缓解6例(3.11%)。近期再出血8例,其中1例死亡。静脉曲张近期治疗总有效率96.89%,远期总有效率99.48%。结论肝硬化食管胃底静脉曲张内镜序贯治疗效果明显,减少出血和再出血风险,提高患者生活质量。     

内镜下食管静脉曲张套扎或硬化联合心得安治疗预防再出血40例分析

目的研究内镜下食管静脉曲张硬化注射治疗(EVS)或食管静脉曲张套扎(EVL)后联合心得安维持治疗预防肝硬化食管静脉曲张再出血疗效。方法回顾性分析40例食管静脉曲张破裂出血患者的临床资料。结果经过内镜下止血联合心得安治疗的病例随访3月~8年,再发出血率22.5%,死亡率20%,明显低于未经内镜治疗的出血患者。心得安等药物长程联合治疗可有效降低门脉压,预防再出血。结论EVS或EVL联合心得安治疗预防食管静脉曲张破裂再出血安全有效。     

内镜下组织胶注射治疗对胃静脉曲张患者症状缓解及疗效观察

目的观察内镜下组织胶注射治疗胃静脉曲张的疗效。方法以我院2012年2月~2014年12月收治的68例胃静脉曲张患者为研究对象,将其随机分为两组,各34例,对照组患者行内镜下胃静脉曲张结扎术,试验组患者给予内镜下组织胶注射治疗,比较两组临床疗效及并发症情况。结果试验组胃静脉曲张消失率、有效率分别为32.4%、100.0%,与对照组的26.5%、94.1%比较差异无统计学意义(P>0.05);两组止血成功率(94.1%VS73.5%)、再出血率(11.8%vs32.4%)、术中出血发生率(5.9%vs26.5%)比较差异有统计学意义(P<0.05)。结论内镜下组织胶注射治疗能明显改善患者临床症状,止血成功率高,且并发症相对少,可作为胃静脉曲张治疗的重要手段。     

内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血疗效观察

目的观察内镜套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血的疗效。方法选择73例食管胃底静脉曲张破裂出血的患者,药物+内镜(生长抑素+内镜套扎术联合组织胶注射)治疗组34例,内科保守治疗(生长抑素+普洛奈尔)组39例,观察两组止血有效率和再出血率。结果药物+内镜治疗组止血有效率94.12%,再出血率5.88%;内科保守治疗止血有效率74.36%,再出血率27.27%。两组止血有效率差异无统计学意义(P>0.05),药物+内镜治疗组再出血率发生率明显低于内科保守治疗组,差异有统计学意义(P<0.05)。结论内镜下套扎术联合组织胶注射治疗食管胃底静脉曲张破裂出血安全有效。     

食管胃底静脉曲张出血行内镜下套扎术的护理

2002年12月～2005年4月，我院收治食管胃底静脉曲张出血患29例采取内镜下套扎术（EVL）治疗，经精心治疗和护理，疗效显，现报告如下。     

Variceal bleeding and portal hypertension: much to learn, much to explore

The newer diagnostic and therapeutic options continue to evolve and important developments have been made in the field of variceal bleeding and portal hypertension. A meeting was held at Baveno to update consensus on different terminologies in relation to portal hypertension. beta-blockers continue to be the mainstay for primary prophylaxis of variceal bleeding, and endoscopic variceal ligation (EVL) is fast emerging as a strong contender. The role of vasoactive drugs in the management of variceal bleeding was assessed. Octreotide and terlipressin were shown to be as effective as sclerotherapy in achieving initial hemostasis, and octreotide was shown to be safe and efficacious in the prevention of rebleeding. EVL was superior to endoscopic sclerotherapy (EST) for obliteration of esophageal varices. Sequential and simultaneous ligation and sclerotherapy were more effective than ligation alone, in reducing the recurrence rate after variceal obliteration. For gastric varices, cyanoacrylate glue continues to be the first line of treatment, and band ligation is being assessed further. Bleeding ectopic varices were dealt by appropriate endoscopic means. Endosonography has developed strongly in the assessment of variceal eradication and prediction of variceal recurrence. Transjugular intrahepatic portosystemic shunting (TIPS) significantly reduces rebleeding rates compared to EVL.     

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation: High-frequency intraluminal ultrasound study

BACKGROUNDThe efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation (EVL) has not been established. AIMTo evaluate the diagnostic correlation of esophagogastroduodenoscopy (EGD) and high-frequency intraluminal ultrasound (HFIUS) for type 1 gastric varices (GOV1) after EVL and to identify the predictability for rebleeding of EGD and HFIUS. METHODSIn liver cirrhosis patients with GOV1, we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1. Endoscopic grading and red color signs were analyzed using EGD, and the largest variceal cross-sectional areas were measured using HFIUS. In addition, 1-year follow-up was performed. Variceal rebleeding was defined as the presence of hematemesis, hematochezia, or melena without other evidence of bleeding on endoscopic follow-up. RESULTSIn 26 patients with GOV1, variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1 (r = 0.36). In 17 patients who completed the 1-year follow-up, variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding, whereas EGD grading was not a predictor of subsequent rebleeding. CONCLUSIONHFIUS measurement is more predictive of GOV1 rebleeding than EGD grading, so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.     

质子泵抑制剂降低预防性内镜静脉曲张套扎术后早期出血风险的临床研究

目的探讨预防性内镜静脉曲张套扎术(EVL)后出血的相关危险因素,并评估质子泵抑制剂(PPI)的治疗效果。方法该研究为回顾性队列研究,共纳入505例首次接受预防性EVL的肝硬化并发食管静脉曲张高危患者。EVL后出血是指预防性EVL术后8周内出血,出血症状包括:黑便或呕血,血红蛋白降低2.0 g/dl。如内镜确诊为溃疡EVL手术部位出血,则定义为EVL后溃疡出血。结果该组患者中14例患者预防性EVL术后出血。单因素分析显示,EVL术后出血的危险因素包括:饮酒、低白蛋白、高总胆红素、高Child-Pugh评分、高终末期肝病模型(MELD)评分、伴随胃底静脉曲张以及不使用PPI药物治疗。多因素Logistic分析显示,伴随胃底静脉曲张(O^R=5.680,P=0.005)和不使用PPI(O^R=8.217,P=0.002)与预防性EVL后出血有关。进一步排除接受胃底静脉曲张治疗的患者,发现未使用PPI药物(OR^=8.827,P=0.008)是EVL术后出血相关的唯一危险因素。结论行预防性EVL术患者应考虑采用PPI治疗,能降低预防性EVL后出血风险。     

急诊内镜下套扎应用于肝硬化食管静脉曲张破裂出血的疗效及安全性评价

目的观察急诊内镜下套扎(EVL)治疗肝硬化食管静脉曲张破裂出血的疗效及并发症,评估其安全性。方法对68例肝硬化食管静脉曲张破裂出血患者进行EVL治疗,从胃食管连接处开始螺旋向上套扎曲张静脉;当有活动性出血,首先套扎出血处静脉,如止血不成功,则在其下方套扎;如出血较多视野不清,则从胃食管连接处盲扎。观察止血效果及并发症。结果急诊止血成功率为94.12%(64/68),术中并发症发生率为10.29%(7/68),术后并发溃疡出血发生率为2.92%(2/68),无死亡发生。结论 EVL是一种快速、有效的止血方法,但术中并发症并不少见,应重视术中误吸、出血等并发症。     

Variceal bleeding and portal hypertension: still a therapeutic challenge?

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.     

微探头超声内镜对肝硬化患者行食管静脉曲张套扎术 治疗的预后价值评估*

目的应用微探头超声内镜(EUS)对肝硬化患者食管静脉曲张套扎术(EVL)治疗的预后评估。方法选择2015年8月-2017年8月于天津市第二人民医院住院治疗的肝硬化患者64例,均进行EVL根治术治疗。EVL根治术后,患者每半年复查胃镜及EUS,随访1年,胃镜观察有无食管静脉复发。EUS观察食管黏膜下静脉曲张及侧枝静脉的最大直径,记录其曲张程度。结果①EVL根治术后1年内,死亡2例,其余62例均完成随访。其中,复发30例,复发率48.4%(30/62);再次出现食管静脉曲张破裂出血患者4例,出血率6.5%(4/62);②与治疗前相比,EVL根治术后食管黏膜下静脉曲张中/重度例数、食管旁静脉曲张及周围静脉曲张重度例数,差异无统计学意义(P0.05);③EVL根治术后,与食管静脉曲张未复发组相比,复发组食管黏膜下静脉曲张中/重度例数明显增多,食管旁静脉曲张及周围静脉曲张重度例数明显增多,差异有统计学意义(P=0.000)。结论应用微探头EUS随访EVL根治术患者,观察食管黏膜下静脉曲张及食管侧枝静脉的程度,对EVL术后食管静脉曲张复发有一定的预测价值。